IF YOU DO NOT KNOW ANYTHING ABOUT PSYCHOLOGY DO NOT TRY TO DO THIS, PLEASE!

1 CLINICAL INTERVIEW/CASE HISTORY 1. DEMOGRAPHIC INFORMATION Name: DOB: Age: Sex: Address: Home Phone: Work Phone: Email Address: Cell Phone: Marital Status: Race/Ethnicity: Religion : Income : Occupation: Language(s): 2. INITIAL/GENERAL IMPRESSIONS OF CLIENT Appearance: Attitude: Behaviors: 3. REA SONS FOR COMING/ PRESENTING CONCERN(S) (As stated by person/family) (Include r eason (s) for coming in, sym ptoms or complaints, including whether or not the complaint is the result of or is likely to end up as a legal issue) WHAT is/are the problem(s)? WHEN did it start? HOW is the problem displayed? HOW serious are these concerns to you? NOT A CONCERN SLIGHT MILD MODERATE SEVERE EXTREME Is this problem likely to end up as a legal issue? If yes, please explain: Additional Comments: 4. CURRENT AND RECENT SITUATION Where do you live, and with whom? Describe to me a typical day o f yours. Where do you go, and who do you see most days? 2 Over the past year, have you experienced any significant life changes? Please tell me about them? Do you think these changes have contributed to the p roblems that you are experiencing? How have you tried to handle the problem so far? What has worked, even if just a l ittle bit? What hasn’t worked? What strengths do you have that could help or have helped you overcome this difficulty? Who can you rely on for support with this problem? Since this problem began, what changes in functioning have you noticed in the following area s? Physical/Health: Emotional: Thoughts: Behaviors: Learning: 5. PREVIOUS ASSESSMENTS AND COUNSELING EXPERIENCES Have you ever been tested for a psychological, educational or career reason? If so, please explain: If so, do you know which tests and the approximate dates that they were administered? 3 What were the results of the test(s)? Have you ever received counseling services before? If so, explain what led to initiation of these services. What interventions were attempted? What were th e outcomes of these interventions? Have you ever been diagnosed with a mental or emotional disorder? If so, which one(s)? Have you ever been prescribed medication to treat a menta l or emotional disorder? If so, which one(s)? 6. BIRTH AND DEVELOPMENTAL HISTORY Do you know how long your mother’s pregnancy with you lasted? Do you know if the pregnancy was planned? Type of Labor? (circle one) Easy Moderate Difficult Length of Labor? Mother’s age at birth? Father’s age at birth Month prenatal care began (circle one): None 1 st 2nd 3rd 4th 5th 6th 7th 8th 9th Baby w as born : Full term weeks early weeks late Baby’s condition, height and weight at birth? Did the mother smoke, drink alcohol, take street drugs or use prescriptions medications during pregnancy? If so, please ex plain Birth Characteristics (check all that apply): ____ Normal delivery ____ Breach delivery ____ Caesarian delivery ____ Induced delivery ____ Forceps delivery ____ Needed oxygen ____ Cord around neck ____ Was a twin ____ Infection ____ Injured (specify) ____ Difficulty breathing ____ Turned blue ____ Jaundiced ____ Seizures ____ Trouble sucking ____ Breastfed ____ Diarrhea ____ Vomited often ____ Constipated ____ Given medication ____ Birth defect (specify) ____ Sleepy/listless ____ Difficulty nursing ____ Blood transfusion 4 Childhood Developmental Issues (check all that apply): ____ Late walking ____ Late crawling ____ Attention problems ____ Overactive ____ Late talking ____ Seizures ____ Late toilet traini ng ____ Bed wetting ____ Sleep problems ____ Defiant ____ Anxious/perfectionistic ____ Depressed ____ Aggressive ____ Clingy ____ Truant ____ Delayed math ____ Delayed reading ____ Shy ____ Frequent tantrums ____ Retained in school ____ Poor coordinati on ____ Easily frustrated ____ Impulsive ____ Poor handwriting ____ Nightmares ____ Frequent crying ____ Fears/phobias ____ Poor appetite ____ Speech problems ____ Soiling of pants ____ Difficulty separating from parent(s) Additional Comments: 7. F AMILY OF ORIGIN/FAMILY CONSTELLATION For your biological family, please provide: Academic Medical Emotional Name Age Education Problems Problems Problems Father: Yes No Yes No Yes No Mother: Yes No Yes No Yes No Siblings/Other: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Please provide details about any family academic, medical or emotional problems indicated above. Academic: Medical: Emotional/Psyc hological: Describe your relationships with key family members: How were rewards and punishments carried out in the home? Were there difficulties in the home not yet mentioned? If so, explain: 5 What changes at home would have made life easier for you? Is there anything else about your family life that we’ve left out and you’d like to tell me about? 8. E ARLY RECOLLECTIONS (Describe people, place(s), events, overall emotional feel of your three earliest memories) Early Me mory #1 : Early Memory #2: Early Memory #3: 9. MARITAL AND FAMILY DATA If you are married, please provide the following information: Academic Medical Emotional Name Age Education Problems Problems Problems Spouse: Yes No Yes No Yes No Child #1 Yes No Yes No Yes No Child #2 Yes No Yes No Yes No Child #3 Ye s No Yes No Yes No Child #4 Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No 10 . M EDICAL HISTORY Tell me about all major injuries or sur geries and the approximate age of occurrence: Are you taking any medications for medical conditions? If so, please list them : 6 Indicate all that apply to yo ur current or past medical history: ____ Ear infections ____ High fevers ____ Trouble hearing ____ Trouble seeing ____ Allergies ____ Asthma ____ Kidney problems ____ Heart problems ____ Seizures ____ HIV/AIDS ____ Pneumonia ____ Bronchitis ____ Men ingitis ____ Numbness/tingling ____ Stroke ____ Coma ____ Head injury ____ Sleep problems ____ Heart attack ____ High BP ____ Heart disease ____ Angina ____ Anemia ____ Lead poisoning ____ Extreme fatigue ____ Memory problems ____ Tremor ____ Attention problems ____ Dizziness ____ Headaches ____ Stomachaches ____ Drug treatment program ____ Diabetes ____ Cancer ____ Neurological issues ____ Poisoning/Overdose Please provide additional information for all of the items checked above: What additional conditions or illnesses have you had or do you currently have? Has any member of your family been diagnosed with any of the following (check all that apply)? ____ Ear infections ____ High fevers ____ Trouble hearing ____ Trouble seeing ____ Allergies ____ Asthma ____ Kidney problems ____ Heart problems ____ Seizures ____ HIV/AIDS ____ Pneumonia ____ Bronchitis ____ Meningitis ____ Numbn ess/tingling ____ Stroke ____ Coma ____ Head injury ____ Sleep problems ____ Heart attack ____ High BP ____ Heart disease ____ Angina ____ Anemia ____ Lead poisoning ____ Extreme fatigue ____ Memory problems ____ Tremor ____ Attention problems ____ Diz ziness ____ Headaches ____ Stomachaches ____ Drug treatment program ____ Diabetes ____ Cancer ____ Neurological issues ____ Poisoning/Overdose Please provide additional information for all of the items checked above: Additional Comments: 11 . E DUCATION AND TRAINING List names and grades attended for all schools and colleges: Wha t is the highest grade/diploma/degree achieved? What subjects were the easiest? 7 What were your favorite subjects to study? What subjects were the most challenging? What were some areas of pride? Difficulty? Did you receive any special services (e.g., IEP, BIP or 504 plans)? If so, please describe? How was you attitude toward school? (Circle one) Excellent Above Average Average Below Average Poor Were you ever retained in grade placement? If so, when? Additional comments: 12. W ORK BACKGROUND /H ISTORY List all of the jobs that you h ave held in the last five years? Describe each job and your level of satisfaction with each: What factors caused you to leave the jobs listed above ? If you are currently employed, what is your current job title and description ? How long have you had this job? What is your level of satisfaction with your current wo rk? Low Average High What aspects of your work do you like best and why? What aspects of your work do you like least and why? 8 13 . R ECREATION, INTERESTS, AND P LEASURES Describe your interests, recreational activities and things that you do for please (e.g., reading , playing sports ). Include any volunteer work that you do. 14 . SOCIAL SUPPORTS, COMMUNICATION NETWORK , AND SOCIAL INTERESTS Descri be the people that you talk to most frequently, the people available to you for various kinds of help, the amount and quality of interactions that you have with people, and your sense of contribution to others and to the community. 15 . S ELF -DES CRIPTION Describe yourself, including: your strengths and weaknesses, your ability to be creative and use imagery, your values and ideals, and anything else that you think is important. 9 16 . CHOICES AND TURNING POINTS IN LIFE Describe the m ost important decisions and choices that you have made in your life. Discuss the impact of each choice. Identify the single most important decision/choice you have made, and explain why it is important. 17 . P ERSONAL GOALS AND VIEW OF THE FUTURE Describe what you would like to see happen in your life in the next year, the next 5 years, and the next 10 years. Describe what is necessary for these events to happen. 18. INITIAL TREATMENT RECOMMENDATIONS (THIS SECTION IS FOR INTERVIEWER USE ONLY . DO NOT ASK EXAMINEE ABOUT TRE ATMENT RECOMMENDATIONS .)